Increased levels of autistic traits are associated with atypical moral judgments.

Despite evidence often showing differences between groups with Autism Spectrum Disorder (ASD) and neurotypical controls in moral judgment, the precise nature of these differences has been difficult to establish. At least two reasons for this are (1) that ASD (and its associated characteristics) is difficult to define and (2) that morality, and the inclinations that undergird it, are hard to measure empirically. These challenges have made conclusive associations between ASD and particular patterns of moral judgment hard to come by. Thus, in the current study, participants levels of a traits associated with ASD were assessed by their responses to a questionnaire (i.e., the Iowa Screener) before they made moral judgments across a set of 20 moral dilemmas that independently assess utilitarian and deontological processing. Interestingly, results indicated that increased levels of autistic traits were associated with fewer moral judgments corresponding to either moral theory; that is, higher levels of autistic traits were associated with atypical patterns of moral judgment. In addition, and consistent with some prior methods (e.g., Gaeth et al., 2016), participant scores on the Iowa Screener, as well as their self-identification, were used to categorize participants between two groups (i.e., ASD and Typical) for exploratory purposes. Taken together, this research better informs the relationship between ASD and its associated traits with moral judgment and can inform certain discrepant findings in the field. Implications and ideas for future research are discussed, such as whether traits associated with ASD might relate to alternative moral inclinations, beyond deontology and utilitarianism.

Corrigendum: Extending decision making competence to special populations: a pilot study of persons on the autism spectrum.

[This corrects the article on p. 539 in vol. 6, PMID: 25972831.].

Time Preferences Predict Mortality among HIV-Infected Adults Receiving Antiretroviral Therapy in Kenya.

BACKGROUND: Identifying characteristics of HIV-infected adults likely to have poor treatment outcomes can be useful for targeting interventions efficiently. Research in economics and psychology suggests that individuals' intertemporal time preferences, which indicate the extent to which they trade-off immediate vs. future cost and benefits, can influence various health behaviors. While there is empirical support for the association between time preferences and various non-HIV health behaviors and outcomes, the extent to which time preferences predict outcomes of those receiving antiretroviral therapy (ART) has not been examined previously. METHODS: HIV-infected adults initiating ART were enrolled at a health facility in Kenya. Participants' time preferences were measured at enrollment and used to classify them as having either a low or high discount rate for future benefits. At 48 weeks, we assessed mortality and ART adherence, as measured by Medication Event Monitoring System (MEMS). Logistic regression models adjusting for socio-economic characteristics and risk factors were used to determine the association between time preferences and mortality as well as MEMS adherence ≥90%. RESULTS: Overall, 44% (96/220) of participants were classified as having high discount rates. Participants with high discount rates had significantly higher 48-week mortality than participants with low discount rates (9.3% vs. 3.1%; adjusted odds ratio 3.84; 95% CI 1.03, 14.50). MEMS adherence ≥90% was similar for participants with high vs. low discount rates (42.3% vs. 49.6%, AOR 0.70; 95% CI 0.40, 1.25). CONCLUSION: High discount rates were associated with significantly higher risk of mortality among HIV-infected patients initiating ART. Greater use of time preference measures may improve identification of patients at risk of poor clinical outcomes. More research is needed to further identify mechanisms of action and also to build upon and test the generalizability of this finding.

Extending decision making competence to special populations: a pilot study of persons on the autism spectrum.

The area of decision making has much to offer in our effort to understand special populations. This pilot study is an example of just such a project, where we illustrate how traditional decision making tools and tasks can be used to uncover strengths and weaknesses within a growing population of young adults with autism. In this pilot project we extended accounts of autistic behavior such as those derived from "theory of mind" to predict key components of decision making in high-functioning young adults on the autism spectrum. A battery of tests was administered to 15 high-functioning college students with autism spectrum disorder (ASD), focusing on decision making competence (DMC) and other aspects of decision making related to known deficits associated with autism. Data from this group were compared to data from unselected college students receiving the same measures. First, as a test of a key social deficit associated with autism, the target group scored much lower on the Empathy Quotient scale. Traditional elements of decision making competency such as Numeracy and application of decision rules were comparable across groups. However, there were differences in thinking style, with the ASD group showing lesser ability and engagement in intuitive thinking, and they showed lower levels of risk taking. For comparisons within the ASD group, autobiographical reports concerning individual lifestyles and outcomes were used to derive a scale of Social Functioning. The lowest scoring individuals showed the lowest levels of intuitive thinking, the lowest perceived levels of others' endorsement of socially undesirable behaviors, and the lowest ability to discriminate between "good" and "bad" risks. Results are discussed in terms of interventions that might aid high-functioning young adults with ASD in their everyday decision making.

Agency modulates the lateral and medial prefrontal cortex responses in belief-based decision making.

Many real-life decisions in complex and changing environments are guided by the decision maker's beliefs, such as her perceived control over decision outcomes (i.e., agency), leading to phenomena like the "illusion of control". However, the neural mechanisms underlying the "agency" effect on belief-based decisions are not well understood. Using functional imaging and a card guessing game, we revealed that the agency manipulation (i.e., either asking the subjects (SG) or the computer (CG) to guess the location of the winning card) not only affected the size of subjects' bets, but also their "world model" regarding the outcome dependency. Functional imaging results revealed that the decision-related activation in the lateral and medial prefrontal cortex (PFC) was significantly modulated by agency and previous outcome. Specifically, these PFC regions showed stronger activation when subjects made decisions after losses than after wins under the CG condition, but the pattern was reversed under the SG condition. Furthermore, subjects with high external attribution of negative events were more affected by agency at the behavioral and neural levels. These results suggest that the prefrontal decision-making system can be modulated by abstract beliefs, and are thus vulnerable to factors such as false agency and attribution.

A neuropsychological approach to understanding risk-taking for potential gains and losses.

Affective neuroscience has helped guide research and theory development in judgment and decision-making by revealing the role of emotional processes in choice behavior, especially when risk is involved. Evidence is emerging that qualitatively and quantitatively different processes may be involved in risky decision-making for gains and losses. We start by reviewing behavioral work by Kahneman and Tversky (1979) and others, which shows that risk-taking differs for potential gains and potential losses. We then turn to the literature in decision neuroscience to support the gain versus loss distinction. Relying in part on data from a new task that separates risky decision-making for gains and losses, we test a neural model that assigns unique mechanisms for risky decision-making involving potential losses. Included are studies using patients with lesions to brain areas specified as important in the model and studies with healthy individuals whose brains are scanned to reveal activation in these and other areas during risky decision-making. In some cases, there is evidence that gains and losses are processed in different regions of the brain, while in other cases the same region appears to process risk in a different manner for gains and losses. At a more general level, we provide strong support for the notion that decisions involving risk-taking for gains and decisions involving risk-taking for losses represent different psychological processes. At a deeper level, we present mounting evidence that different neural structures play different roles in guiding risky choices in these different domains. Some structures are differentially activated by risky gains and risky losses while others respond uniquely in one domain or the other. Taken together, these studies support a clear functional dissociation between risk-taking for gains and risk-taking for losses, and further dissociation at the neural level.

An fMRI study of risk-taking following wins and losses: implications for the gambler's fallacy.

Human decision-making involving independent events is often biased and affected by prior outcomes. Using a controlled task that allows us to manipulate prior outcomes, the present study examined the effect of prior outcomes on subsequent decisions in a group of young adults. We found that participants were more risk-seeking after losing a gamble (riskloss) than after winning a gamble (riskwin), a pattern resembling the gambler's fallacy. Functional MRI data revealed that decisions after riskloss were associated with increased activation in the frontoparietal network, but decreased activation in the caudate and ventral striatum. The increased risk-seeking behavior after a loss showed a trend of positive correlation with activation in the frontoparietal network and the left lateral orbitofrontal cortex but a trend of negative correlation with activation in the amgydala and caudate. In addition, there was a trend of positive correlation between feedback-related activation in the left lateral frontal cortex and subsequent increased risk-seeking behavior. These results suggest that a strong cognitive control mechanism but a weak affective decision-making and reinforcement learning mechanism that usually contribute to flexible, goal-directed decisions can lead to decision biases involving random events. This has significant implications for our understanding of the gambler's fallacy and human decision making under risk.

The impact of prior risk experiences on subsequent risky decision-making: the role of the insula.

Risky decision-making is significantly affected by homeostatic states associated with different prior risk experiences, yet the neural mechanisms have not been well understood. Using functional MRI, we examined how gambling decisions and their underlying neural responses were modulated by prior risk experiences, with a focus on the insular cortex since it has been implicated in interoception, emotion and risky decision-making. Fourteen healthy young participants were scanned while performing a gambling task that was designed to simulate daily-life risk taking. Prior risk experience was manipulated by presenting participants with gambles that they were very likely to accept or gambles that they were unlikely to accept. A probe gamble, which was sensitive to individual's risk preference, was presented to examine the effect of prior risk experiences (Risk vs. Norisk) on subsequent risky decisions. Compared to passing on a gamble (Norisk), taking a gamble, especially winning a gamble (Riskwin), was associated with significantly stronger activation in the insular and dorsal medial prefrontal cortices. Decision making after Norisk was more risky and more likely to recruit activation of the insular and anterior cingulate cortices. This insular activity during decision making predicted the extent of risky decisions both within- and across-subjects, and was also correlated with an individual's personality trait of urgency. These findings suggest that the insula plays an important role in activating representations of homeostatic states associated with the experience of risk, which in turn exerts an influence on subsequent decisions.

Do individual differences in Iowa Gambling Task performance predict adaptive decision making for risky gains and losses?

We relate performance on the Iowa Gambling Task (IGT), a widely used, but complex, neuropsychological task of executive function in which mixed outcomes (gains and losses) are experienced together, to performance on a relatively simpler descriptive task, the Cups task, which isolates adaptive decision making for achieving gains and avoiding losses. We found that poor IGT performance was associated with suboptimal decision making on Cups, especially for risky losses, suggesting that losses are weighted more than gains in the IGT. These findings were significant beyond several notable gender differences in which men outperformed women. Implications for the neuropsychological study of risk are discussed.

The effects of insula damage on decision-making for risky gains and losses.

Several lines of functional neuroimaging studies have attributed a role for the insula, a critical component of the brain's emotional circuitry, in risky decision-making. However, very little evidence yet exists as to whether the insula is necessary for advantageous decision-making under risk, specifically decisions involving uncertain gains and losses. The present study uses a risky decision-making task with lesion patients and healthy controls to investigate the effects of focal insula damage on risk-taking to achieve gains and to avoid losses. Compared to healthy controls, insula lesion patients showed an altered decision-making pattern in domains involving both risky gains and risky losses. Specifically, insula damage was associated with insensitivity to differences in expected value between choice options. Additionally, patients made significantly fewer risky choices than healthy adults in the gain domain. In conjunction with earlier findings, these results suggest that risky decision-making is dependent on the integrity of a neural circuitry that includes several brain regions known to be critical for the experience and expression of emotions, namely the insula, amygdala, and ventromedial prefrontal cortex. However, each neural region seems to provide a distinct contribution to the overall process of decision-making.

Functional dissociations of risk and reward processing in the medial prefrontal cortex.

Making a risky decision is a complex process that involves evaluation of both the value of the options and the associated risk level. Yet the neural processes underlying these processes have not so far been clearly identified. Using functional magnetic resonance imaging and a task that simulates risky decisions, we found that the dorsal region of the medial prefrontal cortex (MPFC) was activated whenever a risky decision was made, but the degree of this activity across subjects was negatively correlated with their risk preference. In contrast, the ventral MPFC was parametrically modulated by the received gain/loss, and the activation in this region was positively correlated with an individual's risk preference. These results extend existing neurological evidence by showing that the dorsal and ventral MPFC convey different decision signals (i.e., aversion to uncertainty vs. approach to rewarding outcomes), where the relative strengths of these signals determine behavioral decisions involving risk and uncertainty.

Neural correlates of adaptive decision making for risky gains and losses.

Do decisions about potential gains and potential losses require different neural structures for advantageous choices? In a lesion study, we used a new measure of adaptive decision making under risk to examine whether damage to neural structures subserving emotion affects an individual's ability to make adaptive decisions differentially for gains and losses. We found that individuals with lesions to the amygdala, an area responsible for processing emotional responses, displayed impaired decision making when considering potential gains, but not when considering potential losses. In contrast, patients with damage to the ventromedial prefrontal cortex, an area responsible for integrating cognitive and emotional information, showed deficits in both domains. We argue that this dissociation provides evidence that adaptive decision making for risks involving potential losses may be more difficult to disrupt than adaptive decision making for risks involving potential gains. This research further demonstrates the role of emotion in decision competence.

Presenting risks and benefits to patients.

OBJECTIVE: To investigate whether patients are influenced by the order in which they learn the risks and benefits of a treatment and whether this effect is attenuated by a treatment's associated risk and/or benefit. DESIGN: Subjects were randomized to review 1 of 6 medical treatment information brochures. SETTING: Waiting rooms of primary care physicians at an academic health center. PARTICIPANTS: Six hundred eighty-five subjects, ages 18 to 70 years. INTERVENTION: Subjects reviewed 1 of 3 treatments for symptomatic carotid artery disease. The first (aspirin) was low-risk/low-benefit, the second (carotid endarterectomy surgery) was high-risk/high-benefit, and the third (extracranial-to-intracranial bypass surgery) was high-risk but of unknown benefit. Patients were also randomized to receive information about risk either before or after benefit. Patients were asked to rate the favorability of the treatment on a scale of 0 to 100 and whether they would consent. Finally, subjects rated how their decisions were influenced by the risk and benefit information. MAIN RESULTS: Subjects evaluating aspirin therapy were influenced by the order of the risk/benefit information. Those learning about risks after benefits had a greater drop in their favorability ratings than subjects learning about risks before benefits (-10.9 vs -5.2 on a 100-point scale; P = .02) and were less likely to consent (odds ratio, 2.27; P = .04). In contrast, subjects evaluating carotid endarterectomy and extracranial-to-intracranial bypass were not influenced by information order. When subjects were influenced by the order of information, they also reported that the treatment's risk had less influence on their decision making (P < .01). CONCLUSIONS: When patients evaluate low-risk medical interventions, they may form less favorable impressions of the treatment and be less likely to consent to the treatment when they learn about the risks after the benefits. Order effects were not observed with high-risk treatments regardless of potential benefits.